complaint·December 4, 2025

The investigation revealed the following : Allegation #1- Staff do not ensure facility has current fire extinguishers. The details of the complaint alleged that the facility does not ensure that fire extinguishers are properly maintained. It was reported that the fire extinguishers have not been serviced or replaced for several years. On 12/4/2025, from 9:30am-3:00pm, the department interviewed staff (S1-S4) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not ensure facility has current fire extinguishers. All staff stated that the fire extinguishers were recently serviced and that they have not observed any that were outdated. The department reviewed the A & A Fire Protection Invoice (Dated: 10/15/24) and observed that they were serviced on 10/15/2024. The department toured the facility and observed that there was a total of 16 fire extinguishers throughout the facility that were recently serviced on 12/2/2025 and all were fully pressurized. Three in the lobby, two in the kitchen, three on the first floor, three on the second floor, three in the garage, one in the storage room, and one in the elevator mechanical room. The facility has not received an invoice for the current year. Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure facility has current fire extinguishers. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation #2- Facility is malodorous. The details of the complaint alleged that the facility is malodorous. It was reported that the facility smells of incontinence, especially on the first floor and in memory care. On 12/4/2025, from 9:30am-3:00pm, the department interviewed staff (S1-S4) and residents (R1-R8) regarding the allegation. 4 of 4 staff denied the allegation that the Facility is malodorous. All staff that were interviewed stated that the facility ensures that the building is free from foul odors like urine, incontinence, and hygiene-related odors on all floors. They further stated that the facility has a housekeeping checklist that the housekeepers follow as well as a caregiver workflow schedule to ensure the facility is cleaned and has no lingering smells. The department interviewed residents (R1-R8) about the allegation and 8 of 8 residents that were interviewed stated that they have not smelled any foul odors that lingers for a long time in the facility. The department reviewed the RCFE Caregiver Morning Shift Workflow (Dated: 6:00am-2:00pm), RCFE Caregiver Morning Shift Workflow (Dated: 2:00pm-10:00pm), and RCFE Caregiver Morning Shift Workflow (Dated: 10:00pm-6:00am) and the House Keeping Daily Checklist (Dated: November/December 2025) and observed that the facility has a round the clock schedule of staff that are tasked at making sure the facility remains clean. Report Continued On LIC9099-C The department toured the entire facility (lobby, first floor, memory care, second floor, kitchen and garage area) and did not observe any foul odors like urine, incontinence, and hygiene-related odors throughout the facility. Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that Facility is malodorous. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Allegation #3- Staff do not ensure facility is properly maintained. The details of the complaint alleged that the facility is not properly maintained. It was reported that the breaker boxes (electrical panels) are outdated and need to be repaired. On 12/4/2025, from 9:30am-3:00pm, the department interviewed staff (S1-S4) and residents (R1-R8) regarding the allegation. 4 of 4 staff denied the allegation that the Staff do not ensure facility is properly maintained. Staff stated that they have not had any issues with the electrical system or breaker boxes in the facility. Staff maintained that all breaker boxes (electrical panels) were in working order. The department interviewed residents (R1-R8) about the allegation and 8 of 8 residents that were interviewed stated that they have not had any electrical issues in their rooms or noticed any electrical problems in the facility. The department reviewed the Maintenance and House Keeping Work Order Log (Dated: November 2025), Laundry Schedule (Dated: December 2025), A & A Fire Protection Invoice (Dated: 10/15/24), House Keeping Daily Checklist (Dated: November/December 2025), Maintenance and House Keeping Work Order Log (Dated: November 2025), RCFE Caregiver Morning Shift Workflow (Dated: 6:00am-2:00pm), RCFE Caregiver Morning Shift Workflow (Dated: 2:00pm-10:00pm), and RCFE Caregiver Morning Shift Workflow (Dated: 10:00pm-6:00am) and did not observe any deficiencies in the way the facility was maintained. The department toured the facility and observed 10 breaker boxes (electrical panels) and observed that they were all in working order and not outdated or in need of repair. The department further observed that the facility was well maintained inside and outside of the facility. Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure facility is properly maintained. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No citations were issued. An exit interview was conducted with Michelle Brown, Wellness Director, and a hard copy of this Complaint Investigation Report was provided.